Taking care of the caregivers. How characteristics of work environment affect patient safety

Background. Patient safety was brought into the forefront of public debate with the groundbreaking report “To Err is Human” (Kohn Lt 1999) calling for quality to be a critical component of high-performing health systems. The patient safety focus shifted from the understanding of patient safety as a product of individual skills and mindset to a new form of quality, which is a byproduct of the complex system interrelationships in healthcare. Yet despite decades of attention, activity and investment, patients continue to suffer preventable harm and improvement has been dismally slow. Dr. Peter. F. Hjort (2007) translated the global patient safety challenge to a Norwegian context and began raising awareness among Norwegian politicians, policy makers and healthcare providers. In response, several system improvement strategies were introduced. This thesis was initiated as a response to the suggested mandatory accreditation requirements for Norwegian hospitals. Accreditation may be associated with high costs and extra workload; thus, a systematic evaluation of the value of accreditation is needed. Regulatory standardization and employee autonomy are often seen as opposing goals. However, reducing the gaps between managers struggling to balance resource constraints and staff at the sharp end of clinical operations might facilitate a work environment supportive of performing safely and with joy under varying environmental conditions. Aims. The overall aim of this thesis is to investigate how health work environments affect patient safety in hospitals. To answer the research question, two perspectives were chosen: a) assessing the effects of accreditation on patient safety and quality of care; and b) assessing the work environment characteristics’ impact on patient survival and safety climate. Methods. This thesis is based on a multifaceted approach including a systematic literature review supported by two studies: a cross-sectional study, and a longitudinal study. i) The systematic review, conducted according to the PRISMA guidelines, evaluated the effects of hospital accreditation on the quality of care and patient safety. ii) The cross-sectional study is based on 8,800 responses from nurses, middle managers, and physicians who participated in a validated work environment survey. The primary end point was the seven-day survival rate. The responses were linked to patient administrative data from 46,000 patients admitted to the hospital and treated with acute myocardial infarct (AMI), stroke, or hip fracture. iii) The longitudinal study’s aim was to investigate the relationships between the perceptions of 25,220 staff in 970 clinical units at 21 Norwegian hospitals about their work environment and the safety climate in their clinical units. The associations between work environment characteristics (exposure) and patient survival probability and the organizational safety climate (outcome) were analyzed using multivariable linear regression models. Results. i) The systematic review revealed a lack of studies with a controlled design. We found only weak conclusions could be reached to support the effectiveness of hospital accreditation on patient safety and the quality of care due to scant and heterogeneous evidence. ii) For the crosssectional study, the factors Workload of nurses Beta 0.0019 (0.009 to 0.028) and Engagement of middle managers Beta 0.024 (0.010 to 0.037) were positively and significantly associated with patient survival but no association was found related to physicians’ actions. iii) The longitudinal study confirmed an association between work environment characteristics and raising a unit’s safety climate to a mature level, and, when present, maintaining a mature safety climate over time. Conclusions. A variety of safety measures to improve patient safety have been suggested and implemented to support safer healthcare. The empirical evidence for the effects of external accreditation on patient safety were inconclusive. Hospital accreditation may be important for ensuring a basic level of quality; however, to be relevant accreditation standards need to support staffs’ work processes in providing safe quality care. Policy makers and management need to carefully consider this when allocating resources to the accreditation processes. The COVID-19 pandemic demonstrated a need for standardization and regulation, and calls on policymakers to involve healthcare professionals and patients more fully to close the gaps between work-asimagined and work-as-done. A work environment that inspires trust, authentic management commitment to improvement, staff commitment, and patient-centeredness might enhance patient safety. This thesis confirms the importance and value of bringing patient safety to the forefront of health policy and care, which can help fulfill the promise to do no harm to patients